The potential of price transparency tools to help consumers with high out-of-pocket medical expenses remains largely untapped, according to two recent studies published in Health Affairs and other recent research by Consumer Reports and Public Agenda.
One study found that while more than half of the nearly 3,000 patients surveyed said they would use a website to shop for healthcare if they knew of one, only 13 percent actually looked for information on future healthcare spending and only 3 percent compared prices and costs across providers.
In the second study, patients with access to a price transparency tool focused on “shoppable” services did not experience overall lower spending on those services, and only 12 percent used the tool to begin with. On a positive note, patients who compared prices for imaging tests decreased spending an average 14 percent.
Research by us at Consumer Reports and a survey by Public Agenda (publicagenda.org) signals additional cautious hope for consumer’s use of price transparency tools in the future. Both projects were sponsored by the New York State Health Foundation (nyshealthfoundation.org) and received additional funding from the Robert Wood Johnson Foundation (rwjf.org).
In late May the science and health news site STAT ran a provocative article titled: “Trump wasn’t always so linguistically challenged. What could explain the change?”
Not surprisingly, the piece went viral. After all, aren’t most of us wondering whether something is up with the President’s—how shall I say it—state of mind, psychological status, character, personality, and yes, mental health?
For over a year, there’s been speculation about this. Most of the talk is loose and politically inflected. But substantive reflections by mental health professionals and serious commentators are on the rise.
At first, media outlets were very careful. They didn’t want to say the president was “lying” let alone possibly crazy. Their caution was grounded mostly in journalistic ethics and policies. But that caution was also attributable to a thing called the “Goldwater Rule,” which warrants explaining because it infuses this whole issue.
It’s open enrollment season—the annual period in which tens of millions of consumers wallow in the misery of health insurance choices and costs. So, let’s pause to reflect on the status of things—enrollment-wise—with employer coverage, Medicare, and the exchanges.
In particular, do consumers have better tools these days to help them choose insurance plans?
For people with employer-based coverage—about 150 million Americans—things are okay and stable, but not great. The latest report from the Kaiser Family Foundation, released last month and based on a detailed survey of 1,900 employers (small, mid-size and large), indicates that premiums rose on average a modest 3% in 2016—to just over $18,000 for family coverage. Workers paid 29% of that.
A similarly small increase in premiums has prevailed for several years and is expected again for 2017.
Almost all firms with 50 or more employees offer health benefits and the vast majority claim their coverage meets the ACA’s requirements for value and affordability. Overall, 56% of employers offer health benefits because hundreds of thousands of small firms either choose not to offer it or can’t afford it—especially the smallest Mom and Pop shops.
Well, it’s not Zika and it won’t kill you, but pornography is being discussed—seriously—as a public health problem, even a “crisis.”
The path to this claim is a long one, with a slow burn over many years. It was kicked into higher gear in recent months with:(a) legislative action in one state;(b) a coverstory in TIME magazine (April 11 issue);(c) a Washington Post op-ed piece by anti-porn advocate Gail Dines; (d) a response to that in Atlantic Monthly; and (e) the publication of two books that discuss at length the effect of porn and the new sexual culture on teen girls—American Girls-Social Media and the Secret Lives of Teenagers by Mary Jo Sales and Girls & Sex-Navigating the Complicated New Landscape by Peggy Orenstein.
The legislative action took place in Utah. The Republican-led House of Representatives in that state became the first legislative body in the nation to pass a resolution declaring pornography “a public health hazard leading to a broad spectrum of individual and public health impacts and societal harms.” Dines and her fellow anti-porn crusaders want to carry that fight to other states.
This is going to be fun to watch! (Pun intended.)
Giving consumers information and data on providers’ quality of care and clinical results is one important path to enhanced transparency, patient engagement, and better health care.
Two publications out this month add significantly to the dialogue on this issue. The journal Health Affairs devotes most of its April issue to the theme of “patients’ and consumers’ use of evidence to inform health care decisions.” And the cover story in the May issue of Consumer Reports is entitled “What You Don’t Know About Your Doctor Could Hurt You.” Accompanying that story online is Consumer Reports’ latest ratings of doctors in six states and two metro areas.
(Disclaimer: I contributed an article to the April issue of Health Affairs and was involved in one element of the Consumer Reports piece.)
Among observations in the Health Affairs papers:
Star-based provider ratings, summarized information (instead of details) and well known signifiers of quality such as blue ribbons work best to compel consumers to both pay attention and make wise choices among health plans and providers.
Getting consumers to consider quality and cost (and the concept of value) remains a challenge. A survey of some 2,000 people found that most don’t think cost and quality of care are necessarily related. That’s good and bad. Good because previously published research indicated that most people leaned to believing that higher price means better quality. Bad because the new survey signals that people are still disconnected from pursuing value in health care by consciously choosing lower-cost/high-quality providers. Continue reading…
The Obama Administration this month released final numbers on enrollment for the 2016 coverage year in the health insurance exchanges, as well as overall statistics on coverage gains to date under the Affordable Care Act (ACA).
The numbers emerge as the ACA turns 6 years old this week—on March 23. They were also released just as House Republicans issued their proposed 2017 federal budget. That budget, once again—you guessed it—repeals the ACA. The Republican budget is a counter to the Administration’s budget proposed in February. The release of both triggers the annual bruising battle over funding of the federal government, which again this year could end in prolonged stalemate.
You could be cynical or blasé about the Republicans’ persistent mission to kill the ACA—that is, if you don’t support that mission. But I think this piece of political theater continues to warrant contempt. Why? Because even if a Republican were elected President in November, the law is now technically impossible to gut completely. And Republicans know it.
There are a host of reasons the law cannot be nixed in its entirety, and these deserve more attention and discussion, on THCB and elsewhere, at a later time. In the context of this blog, I’ll just point out the obvious: it would simply be unacceptable (and political suicide) to strip 15 to 20 million people of their coverage. In addition, realistically, any insurance scheme to replace Obamacare would very likely be structured in a similar way—through private-sector insurance companies and plans operating in a regulated marketplace for people without employer-sponsored coverage. That’s why Republicans rarely talk about alternatives to Obamacare in any detail.
Oh, for heaven’s sake! Just when we thought we knew one important path to retraining healthcare costs—by mimicking what communities with lower Medicare costs do — along comes a study that blows that idea out of the water.
The landmark new research, unveiled this week in The New York Times, found that communities with lower Medicare hospital spending don’t necessarily have lower hospital spending for privately insured people.
That matters because for the last 10 years or so we have assumed that where Medicare costs were high (or low), privately insured costs would be high (or low), — in short, that there was a correlation. It just made sense.
President Obama trumpeted this relationship in the run-up to passage of the Affordable Care Act, sometimes citing Atul Gawande’s now-famous June 2009 New Yorker article on McAllen, Texas. Obama advised health leaders nationwide to study communities with lower Medicare costs and learn from their cost-cutting ways.
Fifteen years after the landmark IOM report To Err is Human, we still haven’t figured out how to count medical errors and iatrogenic harm—let alone sharply reduce them. The debate surrounding this persists, as it must. For example, see the dialogue on THCB between Anish Koka and John James on the often-used figure of 400,000 deaths per year from medical errors. See also this Health Affairs blog from 2012 by Michael Millenson.
A simple answer to why it’s so hard to count medical errors, harm and deaths is that—well, it’s just a damn hard thing to do. Think about it: how on earth would we document every mistake, even fatal ones. It seems nearly impossible. It’s not like counting auto accidents or plane crashes. The majority of medical errors occur at a nuanced level, but yet can have profound effects down the road, as the IOM’s report on diagnostic errors recently emphasized.
A more complex analysis of why medical errors are hard to count and prevent would start with the fact that reporting is still largely voluntary. For example, we know next to nothing about medical errors in doctor’s offices and outpatient surgery centers, and we don’t have a complete picture for hospitals.
Then there’s the whole issue of which medical mistakes are truly preventable and should be counted as such—that’s part of the debate between Koka and James. The upshot: preventability remains very much in the eye of the beholder. Patient safety activists argue that the debate over preventability is a diversion from pursuing a strategy of zero tolerance for errors. As support, they often point—justifiably—to success stories where concerted efforts have led to dramatic reductions in errors and hospital acquired infections. But doctors have long countered that medicine is a human enterprise that can never be perfect, that mistakes are inevitable, and that they have less control over medical outcomes than is often assumed.
Earlier this month the Center for Public Integrity (CPI) published a sharp-edged piece on PCORI—the Patient-Centered Outcomes Research Institute.
The piece raised some salient issues and it’s timely to take stock of PCORI at the half way point of its authorized funding. (Unless renewed, PCORI sunsets in 2019.)
The Affordable Care Act created PCORI as an independent nonprofit (non-government) entity. But PCORI’s funding and structure makes it more or less quasi-government. It gets its money from the Medicare trust fund, treasury general funds, and a tax on private insurers and self-funded insurance plans ($2.08 per covered life). PCORI launched in late 2010 and began funding research in earnest until 2013. The main focus of that research, mandated by Congress, is to compare treatments in a way that results in meaningful results for doctors and patients as they make clinical decisions. No small task.
The CPI piece probes the emerging debate about how PCORI is being operated and spending its money—roughly $450 million a year in 2014 and 2015. The core lead-in graph of the piece: “On both the right and the left, there’s simmering doubt about whether the unusual nonprofit can live up to expectations, or even what those expectations should reasonably be.”
The report airs legitimate concerns but it skews overly critical and doesn’t fully appreciate the challenge PCORI faces. As someone who labored in the fields of comparative effectiveness for several years, I think PCORI deserves time to get fully underway and prove itself. It certainly doesn’t need ideologically driven attacks and budget threats just because it was launched by the ACA. (The House Appropriations Committee in late June voted to cut PCORI’s funding by $100 million, dubbing it wasteful spending.)
Doctors are human. Their talents and skills differ. They make mistakes. And as with every other area of human endeavor: some doctors are really good; some are pretty bad; most are average. If you are over age 50, you’ve likely met an example of all three.
In the past decade there’s more open recognition of this reality and the need to address the failures it creates in medicine and the delivery of care. There’s more willingness now to say out loud that it’s not just poor system dynamics or gaps in planning, knowledge or training leading to poor care and bad results; it’s also the differential skills and ability of the people delivering care.